Medical marijuana

Cannabis: the comeback of a banned medicine

Luigi Jorio / Thomas Kern / Carlo Pisani

“When pure and administered carefully, [cannabis] is one of the most valuable medicines we possess,” wrote British physician John Russell Reynolds in 1890, praising the substance’s curative properties. He even prescribed it in the form of a natural tincture for his most illustrious patient, Queen Victoria.

Over a century later, cannabis, also known as hemp or marijuana, is on the list of banned substances worldwide due to its psychotropic effects. A devastating and dangerous drug for some, a medicine without equal in the pharmacist’s repertoire for others, cannabis is beginning to be used again in the treatment of serious illness and chronic pain.

In Switzerland, a growing number of patients and doctors are making use of medicines containing cannabis and THC (tetrahydrocannabinol), its psychoactive constituent. Pioneers have worked to give cannabis a new lease of life in medicine, including in Switzerland. In this article swissinfo.ch tells the stories of four people: a grower, a pharmacist, a doctor and a patient. They point out the virtues but also the limits of one of the most controversial medicinal plants in history.

Cultivation

“Let’s say we are in eastern Switzerland near Lake Constance. That will do.” Markus Lüdi has nothing to hide and he is not on the run from the police, yet he prefers to be discreet. His plants of Indian hemp, two metres high, might attract unwelcome attention and the botanical chemist wants to keep curious eyes away.

Someone who likes to smoke the stuff might get ideas, he says, “but he would be disappointed here”. The plants contain no more than 5% of the psychoactive constituent THC – “too small a concentration for anyone looking for a marijuana rush”, Lüdi notes, welcoming swissinfo.ch to his open-air grow-op.

We are on a piece of land belonging to a research and development company for vegetable raw materials. Here, not far from the main road and the campgrounds on the lakeshore, Lüdi rents a field to grow hemp between other fields of corn and potatoes. His idea, he says, was always to grow the plants in the open air, without the use of pesticides or fertilisers.

We go through a metal fence. Covered in a sheet of plastic, about 200 cannabis plants are maturing. Lüdi, who wears a white coat and latex gloves, is about to reap the annual harvest.

Harvest time

For Bern chemist Markus Lüdi it's a special day: after months of waiting the time has come to harvest the cannabis, so that medicine can be produced from it.

“THC is the molecule used in medicine. But it is a narcotic. A sufficient amount of CBD offsets the psychotropic effects.”

Markus Lüdi, chemist

The plants are the result of long selection, he explains. What is important is not the percentage of THC, but the proportion of THC to another active constituent of cannabis, cannabidiol (CBD). “THC is the molecule used in medicine. But it is a narcotic. A sufficient amount of CBD offsets the psychotropic effects.”

“Everyone told me it would never work”, says Lüdi, recalling reaction to his decision to cultivate an illegal plant. It was the end of the Nineties, and the Bern chemist, who worked for a company producing vegetable essences, was convinced of the therapeutic and economic potential of cannabis.

He says there was a kind of cannabis boom at the time, with new applications in the medical field. “I thought the law would soon change. Instead I had to wait more than ten years.” The shift came in 2008, when the Swiss voters approved the medical use of cannabis. Yet it was only in 2011, when the new legislation came into force, that Lüdi received the necessary official authorisation – the only one in Switzerland – to produce and sell a tincture of cannabis.

What does the law say?

Swiss legislation forbids the cultivation, consumption and sale of cannabis with a THC strength of over 1%. Apart from this percentage, cannabis is considered a drug and any use of it requires special authorisation.

In 2008, Swiss voters rejected an initiative to decriminalise cannabis. At the same time they approved the new federal legislation on narcotics, which introduced a controlled and limited use of cannabis for medical purposes. Before then it was allowed only in research.

The Swiss cabinet and the House of Representatives support the idea of a pilot project to examine the feasibility of approving medicines using cannabis.

Medical use of the plant is legal or tolerated in several European countries (Germany, Italy, Spain, Portugal and Britain), Latin America and in 23 American states. It remains illegal in most of Asia and Africa.

Halfway through the afternoon the harvesting is finished. Lüdi is satisfied: he has reaped about 100 kg of marijuana. The pungent smell of the resin fills the air and gets into clothes. Once dried, the hemp will go to a laboratory in Burgdorf, canton Bern, for extraction of the active constituents. It’s a very simple process, he says. “You could do it at home.”

How cannabis becomes medicine

Chemist Markus Lüdi is Switzerland’s only producer of a natural tincture made from cannabis. In his laboratory in Burgdorf in canton Bern he demonstrates how a liquid drug can be produced from cannabis flowers.

The cannabis contains around 5% THC (tetrahydrocannabinol), the psychotropic substance of the plant with therapeutic properties.

The inflorescences are separated from the stems and leaves – painstaking, tedious work that is done by hand.

After the work is finished, only a quarter of the original 150 kg cannabis crop is left.

The approximately 40 kg of crushed cannabis flowers are kept in a refrigerator.

The cannabis flowers are poured into a 70% alcohol solution.

To remove the THC and other cannabinoids, the solution is stored for at least half an hour at room temperature, and then filtered.

This procedure is repeated two to three times.

The objective is to obtain a solution containing 10 mg of THC per millilitre.

Out of 40 kg of cannabis flowers, around 120 litres of tincture can be produced.

Each production step is standardised and all data are recorded.

The cannabis tincture is then sold in pharmacies.

Lüdi has a special permit from the Federal Office of Public Health. All structures involved with cannabis have to meet safety and security criteria, and the whole production is subject to rigorous controls. And so it should be, Lüdi says. He shakes his head, though, when he talks about the amount of bureaucracy involved. Growing the mother plant, starting a new plantation, getting rid of vegetable residue at the end of the harvest – for every phase in production he has to make a special application.

The requirement for permits, he realises, protects him from anyone else trying to do the same thing. He started working on cannabis “because of an ideal”, he says. “This is a plant that can give relief for many serious illnesses.” At 60, he hopes to recoup his investment. 2015 is the first year he has been able to make a living out of the cannabis. What kind of sums are we talking about? “A few hundred thousand francs a year,” he says, adding that “you don’t get rich on [this] grass”.

The cannabis chemist

“Patients come to me when other medicines have failed to produce results.”

Manfred Fankhauser, chemist

In what used to be a bicycle storage room, there is a flurry of activity. Like every afternoon, Manfred Fankhauser and his assistants are preparing the parcels for dispatch. The post office closes in a few hours and there is no time to lose.

Cannabis medicines are lined up on a shelf, 24 boxes for the same number of patients throughout Switzerland. Most contain a THC-based solution, dronabinol, a medicine which Fankhauser prepares directly in his pharmacy in Langnau, canton Bern. Then there are the natural tinctures made by Markus Lüdi, his business partner.

Cannabis acts against nausea and vomiting in patients undergoing chemotherapy. It stimulates the appetite in AIDS patients and relieves spasms in multiple sclerosis. “Patients come to me when other medicines have failed to produce results,” he says.

In 2007, when he started working with cannabis, there were five patients; today there are about 600. With new requests coming in every week, Fankhauser has taken on an assistant just to field calls. And the place where he used to keep bicycles in his family home has been transformed into a “cannabis depot” under video surveillance and alarm. His raw material, pure THC in glass vials, is kept in a safe.

The poster for “Devil's Harvest”, a 1942 film that demonised cannabis consumption

Fankhauser, 52, was the first chemist in Switzerland to put cannabis back on pharmacy shelves. “The medicinal properties of cannabis sativa have been known for thousands of years,” he explains. He knows his subject, for he teaches a course on the history of pharmacy at the federal institute of techology ETH Zurich.

Between 1850 and 1950, in Switzerland and in industrialised countries there were over 100 medicines containing cannabis, he says.

Difficulty of supply at the end of the Second World War (the plant was grown in India), the rise of more stable and efficacious chemical medicines and the growing demonisation of marijuana, which culminated in an international ban in the 1960s, put an end to its use. Manfred Fankhauser recalls that “Swiss law forbade medicinal use of any part of the plant”.

However, he points out that there was no ban on synthetic cannabinoids. This loophole allowed him to get authorisation to import THC obtained from lemon rind from Germany in 2007.

But as a farmer’s son, Fankhauser is eager to use the whole potential of a plant “without equal in the vegetable world”. His idea is a natural extract to be made in Switzerland – a tincture of cannabis, as in the days of Queen Victoria. Unlike dronabinol, this tincture would contain not only THC but all the active ingredients of cannabis, he notes.

Meeting Lüdi and the new law on drugs in 2011 were the beginnings of a success story he hardly expected.

Since then he has become known in his village as “the cannabis chemist”, he recounts with some amusement. Most of the medicines with cannabis now distributed in Switzerland are made in his pharmacy in Langnau – an ordinary chemist’s shop in the middle of town.

He stresses that his motivation is the patients. “When you hear some patients talk, you realise the extent of their suffering.”

Fankhauser does not deny that cannabis is profitable and represents 20% of his sales.

The prices he charges are high, he admits. “But it is really a question of supply and demand: cannabis remains a niche product.” The niche is getting bigger, though: competition from within Switzerland and outside is growing and new preparations are appearing on the market, from orally administered sprays to hemp oil.

Making a medicine out of cannabis is not a simple matter, he points out. The costs – for lab analysis, quality control and ensuring the stability of the product – are high, and the THC he imports to produce dronabinol costs up to CHF1,700 ($1,815) a gram. The bureaucratic effort required is considerable, with permits needing to be renewed every three months, and despite the increasing openness, the stigma surrounding cannabis remains a problem, he says.

Fankhauser knows he has no latitude for error, whether in dosage or in the dispatch of medicines. He is under the watchful eye of the cantonal pharmacy officer, who periodically has to justify the medicinal use of cannabis when dealing with local politicians and health authorities. The difficulty, as Fankhauser points out, is always getting beyond the drug taboo and drawing a line between recreational use and medical applications.

The doctor

Claude Vaney, head neurologist at the Berner Klinik in Crans-Montana, canton Valais, has no doubts. “Cannabis is a medicine,” he says. Unlike morphine, it does not cause addiction and there is no lethal dose, he says. People can overdose on sleeping pills as a way of committing suicide; with cannabis it can’t be done.

It was a patient of his, 20 years ago, who led him to discover cannabis. “He told me that to relieve pain, he smoked a joint,” recalls Vaney.

Curious about this, he obtained a grant from the federal government to study the effects of cannabis (administered in capsule form) on multiple sclerosis patients. “The objective level of spasticity as measured did not change. The subjective level did: the patients said they felt better and slept better at night,” he explains.

“Cannabis relieves pain, it won’t cure the disease.”

Claude Vaney, neurologist

Vaney, 63, is consulted not only by multiple sclerosis patients, who have an incurable disease that affects 8,000 people in Switzerland. There are also people suffering from spinal cord injuries (caused by road accidents or falls), fibromyalgia and severe migraines.

“I tell them to start with a small dose, taken in the presence of another person, and see how it works. I always emphasise one thing: cannabis relieves pain, it won’t cure the disease.”

The doctor from Lausanne has no illusions: cannabis is not a panacea. In his experience, it helps in 30-40% of cases. “Its potential is not fully known at all,” he points out. He believes that growing knowledge about the receptors of THC and other cannabinoids in the human body may lead to the discovery of unrealised therapeutic potential.

Like the grower and the pharmacist, Vaney needs a special authorisation from the health authorities. In the eyes of the law, he has to take full responsibility for prescribing cannabis.

Doctors prescribing cannabis are a growing number (350 in the first five months of 2015 compared with 250 over the same period in 2014) but remain “a minority”, says Gert Printzen, who is on the steering committee of the Swiss Medical Association. The use of cannabis for particular purposes is not in dispute and there are excellent scientific publications to back it up, he told swissinfo.ch by email.

The reticence, he notes, is more on the side of public opinion and the politicians. When you talk about therapeutic use of cannabis, it is always a political issue, he says, but narcotics and medicine need to be distinguished.

This distinction is not so clear-cut for Andrea Geissbühler, a police officer and parliamentarian for the conservative right Swiss People’s Party. “Cannabis remains a drug and the risk of abuse is great. Generalising distribution of medicines is a step on the way to legalisation,” she maintains.

Yet cannabis is a substance with therapeutic merits worth trying, insists Vaney. The patients are not looking for a drug experience but simple relief, a feeling of well-being.

The patient

Monika Koella, 58, has pains all over – in her back, her neck, her joints, her stomach. Part of her intestine is missing and a neurostimulation implant under her skin is sending constant electrical impulses to her brain. Despite about 40 surgeries and all sorts of tests, she cannot put a name on her illness.

Doctors have not been able to diagnose it, she tells swissinfo.ch in her home in Bern. The only thing she is sure of is the reality of chronic pain for over 30 years.

“Cannabis is my life saver.”

Monika Koella, patient

To relieve the pain, she has tried everything: pain-killers in ever larger doses, opiates and experimental treatments. All in vain. At some point the initial relief always disappeared and the side effects became more and more burdensome.

One day a friend showed her a pamphlet. “It talked about a medicine with cannabis, dronabinol. I found it interesting and had the urge to try it.” Three years later, cannabis is her “life saver”, she says. She still takes her daily cocktail of seven medicines. She cannot do otherwise. But since she discovered Manfred Fankhauser’s drops, she has reduced consumption of opiates and sleeping pills.

“It is only a question of time before cannabis returns for good to pharmacy shelves.”

Rudolf Brenneisen, pharmacologist

Twelve drops a day, usually in the evening, are not sufficient, and Koella would like to increase her dose – not to increase the effect, but to spread the drops over the day so that she always has some THC in her bloodstream.

But every drop is precious. Her little bottle of medicine, which lasts her less than two months, costs CHF900. This cost is covered by her health insurance – for now. She is afraid that the insurance company may stop paying; it would have that right under current law. About half such requests to health insurance companies are accepted, says the Federal Office of Public Health.

For Margrit Kessler from the centrist Liberal Green Party, this is not sufficient. As president of the Swiss Patients Organisation, she wants to see automatic and easy approval of medicines using cannabis. The approval procedure is complex and the prices of natural medicines are too high, she has stated in a parliamentary motion.

Under the current system, she believes, many patients dealing with chronic pain prefer to self-medicate – illegally. In June, a substantial majority of the House of Representatives accepted her motion, and the government now favours the idea of a study “to clear up the scientific, methodological and legal questions regarding the use of cannabis flowers”.

In the meantime, Koella prefers to take her drops accurately. Sometimes not even the dronabinol has an effect. But living without her “miraculous” little bottle of medicine would be unthinkable. “It has given me back part of my life,” she says.

Calling cannabis “the aspirin of the 21st century”, as some do, is an exaggeration, Fankhauser thinks. “For almost all the situations where it can be used, there are other medicines too.” But he hopes that patients will be able to get access to cannabis in a timely manner and not as a last resort.

It is only a question of time before cannabis returns for good to pharmacy shelves, Brenneisen believes. “It is enough to look at what is happening in a number of American states or in Uruguay.”

Equally optimistic, Vaney expects that in five to ten years, use of cannabis in Switzerland will be widespread. “Free sale of cannabis for therapeutic purposes could help [patients] live better.”